Advice for Graduating Fellows and Spanning Plates

Chuck and Chris provide 7 pearls for graduating fellows before diving into a discussion on spanning plates.  Also in this episode- learn some of the ways that Chris is 'risk averse'.

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Transcript

Charles Goldfarb: 0:00

Chuck, welcome to the Upper Hand Podcast where Chuck and Chris talk hand surgery.

Chris Dy: 0:09

We are two hand surgeons at Washington University in St Louis, here to talk about all things hand surgery related, from technical to personal.

Charles Goldfarb: 0:17

Please subscribe wherever you get your podcasts, and thank

Chris Dy: 0:20

you in advance for leaving a review and rating that helps us get the word out. You can email us at handpodcast@gmail.com so let's get to the episode.

Charles Goldfarb: 0:30

Oh hey Chris,

Chris Dy: 0:31

Hey Chuck. How are you?

Charles Goldfarb: 0:32

I'm fantastic. I'm at the office on the Saturday morning. What could be better?

Chris Dy: 0:36

Oh, yeah, absolutely. It sounds like you must have been rounding then

Charles Goldfarb: 0:40

I was rounding, but my day started. I woke up a little too early, and I happened to wake up just before I got a text from Emily zoldos, who's winding down her fellowship. And she said, just wanna let you know there's a flexor tuna syntheta. So I'm like, I'm there, so I was gonna come in anyways around, as you said, and I rode early on my bike through the park, which gives me a little trepidation when it's pitch black. And the only weird part about it was those kind of swampy areas in the park, whether it's still water, I felt like I wrote it was like I was driving a car through a bunch of bugs. Oh, it was disgusting. But I mean, one

Chris Dy: 1:25

of the things, one of the things that you know as as well pubs publicized. Now, I'm more of an indoor warrior in terms of working out, just because I like the predictability of the conditions and but occasionally I will go for runs when it's super nice outside, or when I'm traveling. That's mainly when I run. And, you know, I remember running in Forest Park last summer and just being like, did I swallow a bug like and I can only imagine how it is magnified in so many ways when you are on a bike, on

Charles Goldfarb: 1:55

a bike, riding as fast as I I ride. I mean, come on. And I was kind of doing the bullfrog through the Bug, bug storm. It

Chris Dy: 2:04

was funny. So I was talking with one of our partners, David Brogan, who is an accomplished runner and just recently qualified for the Boston Marathon. So congrats to him. And he was talking about one of the races he'll be doing next year as a bit of a tune it up for Boston. It was trying to get me to do it with him, and I'm very well might. It's the the Napa half marathon, you know? And this is going to sound ridiculous to many listening, but my baseline fitness goal is to always be able to run a half marathon without training, which I had I'm there, like, you know, I've done occasionally, just like, kept running sometimes, like, Forrest, Gump, there's one time I'd I was running and as it was a, kind of like a six mile loop. And I said, I'm going to do it one more time, just to text David that I did it. And I did and it's fine. So I was thinking about running that. And then I was like, You know what, David, like, you probably are going to be a triathlon guy. He's like, You should too. I was like, yeah, the swimming terrifies me. I was like, the biking really terrifies me, because the number of people that I see then you two who have had very bad injuries biking, you know, interactions with cars or just falls or, yeah, it scares me. And I'm just, I think I'm too chicken now at my my wise age, No, it's true. Take that up. It's true. I

Charles Goldfarb: 3:16

don't think I've ever had that infinite capacity. My brother kind of is really fit, and when he was in his early 50s, just went around the New York Marathon, which was insane to me. He couldn't walk for a couple of days, but he was able to do it. That's That's not in my DNA, but I will say both joy and pain this morning, so I came in early, worked with one of the overnight scrubs at Big Barnes hospital, and someone I hadn't seen in like, 10 years. Wow. And his first question was, you still play a ball? No,

Chris Dy: 3:49

I'm not. Oh, that's, that's so Oh, man, yeah, that must be tough for you not to, not to play ball anymore. It

Charles Goldfarb: 3:56

is. I'm just happy to put one foot in front of her.

Chris Dy: 4:01

Well, you know, I don't know what it was yesterday I woke up this morning just feeling a little more sore. And I don't know if it's because I did a, you know, bit of a different workout yesterday, or because we were in an all day Plexus. I'm not sure which one it was, but it's probably a combination of

Charles Goldfarb: 4:13

the two. Exactly, right? It's probably a combination. When we're done with the pod, my daughter, the runner, is going to go run eight or 10, or whatever she's going to do. And then we're actually going to dedication of the new basketball courts in Forest Park. This my day is Forest Park, and so I'm going to meet her halfway, and I can't run with her, so I'm going to bike with her, and then and then go to this. So it'll be a nice day,

Chris Dy: 4:34

very cool. Now, is running a goal again, or, like running again? Is that a goal for you, or is that something that you just decided you're going to

Charles Goldfarb: 4:42

shelf I'm going to choose my words carefully. Jogging is a goal again. I've been assured I can. The only thing that makes me a little worried is for getting to that six month mark after my knee replacement, and I'm not ready to run or jog. So we'll see.

Chris Dy: 4:58

I'll be seeing your your knee. Sir. This afternoon for a family gathering. So I will, I'll prod him a bit,

Charles Goldfarb: 5:05

yeah, tell him school farms not making you look good living around the

Chris Dy: 5:09

hospital and publicizing it on the podcast. So before I wanted to get into we have couple topics to talk about today. We do have some, you know, some time of the year for fellowship graduation. But before we get into that, I wanted to thank our friends at practice. Link, the upper hand is sponsored by practicelink.com, the most widely used physician job search and career advancement resource. Becoming

Charles Goldfarb: 5:30

a physician is hard. Finding the right job doesn't have to be join practice link, for free today@www.practicelink.com backslash the upper hand. I think you're the topics are great. We had talked about a couple different clinical topics. I'm not sure which one we landed on, but the fellow graduation theme, I think, is always fun.

Chris Dy: 5:52

It is. It's a it's like, it's a great time of the year. And then, as if, as faculty, you're like, Wow, here we go again. Like, you know, we've got to start this whole process again. It is great to see how our fellows, at least in our microcosm, our fellows, have grown tremendously over the year. You know, as I was doing the the plexus yesterday, I popped over and was watching them, one of them operate. And it was, it was just nice to just see the decision making and the X rays. And like, yeah, you know, you guys have come a long way, and you were great to start, and now you're this is, I like to think of our fellowship as a finishing school, because we are fortunate enough to get incredibly talented fellows. When they walk into the door, they have different strengths in different domains of hand surgery, and then we just get them all to the, you know, to the same point by the end of it, and it's just great to see the evolution.

Charles Goldfarb: 6:43

Yeah, I think there's a couple of all of that is certainly true. And every fellow has his his or her own path. They come with different skill sets, they come with different knowledge bases, but they do really end up in essentially the same spot. And so it's just super fun to watch. It's gratifying to watch. Is fun to watch, and they are, you know, we were talking yesterday, I was in our COH clinic. And then, you know, doing at least one case, and just the joy of obviously approaching fellowship graduation is one thing, but you start to see how meaningful they are to each other, and working together is something that you know, you and David get to do on occasion, and I get to do with Lindley, but it's not something every hand surgeon has the opportunity to do all the time, and it really is super fun. So for those listening who have that opportunity to don't take advantage of it. You should. It's revitalizing. It's fun. But the fellows get to do it some, and they love it.

Chris Dy: 7:40

Yeah, no, I think it's, it's fun to do every time that So David and I have a dedicated Plexus or day once a month. And I was describing it to our new micro fellow as operating like operating with your annoying cousin that you love. Or I was gonna go big brother, little brother, but I couldn't decide who was who in that scenario. But, yeah, it's a fun time, and it is. It definitely brings out the best in each of you as surgeons, and it's great for patient care. It moves cases along, makes decision making better and less stressful. So is that advice number one that you would give, you know, graduating fellows? Is it you know, for if you're tackling big cases, do it with somebody else, or work with a senior partner, or something like that.

Charles Goldfarb: 8:25

Yeah. So I'm gonna put us both on the spot and say that we're gonna give seven pieces of advice,

Chris Dy: 8:31

seven each, like seven total. Nobody's counting. So that's number one.

Charles Goldfarb: 8:37

That's number one. It wasn't a planned one. I don't know that I have three in my head, but we'll get there. Yes, I think. And then, as I mentioned, Linley and I get to operate almost every week. But for example, next week we have a politicization and a hypoplastic thumb reconstruction, two different cases, and those are cases we do together. We don't we're in the same spot. We don't always operate together, but it does bring so many advantages to ourselves, to the patient. It moves the case along. I think results are better, but it does. You know, operating in isolation is fine, but you you miss something, you lose something, and so bringing that partner in, or it could be, I guess, a very close surgical assistant could bring the same level of satisfaction and joy, I guess. But I think operating with a partner is a whole different level,

Chris Dy: 9:30

yeah. And I think, you know, it's obviously not a viable thing for the vast majority of cases, but you know, especially early on, I think if you're tackling a complex case, it could be like a one off kind of thing. But if it's case where you are either not feeling as comfortable and you want to bounce decision making off of or, you know, you just need somebody else to help keep the case moving along. If it's like a multi step kind of thing that involves, like, nerve grafting and somebody harvesting something else, I mean, it's just it makes sense, and I think as a partner, I'd be happy in it. You know, relieved that a junior person who was starting was reaching out. Because, you know, the hard, I think the the confidence as a surgeon, as a surgeon starting out is a very challenging thing, because you want to come across as confident and capable. But the, you know, Achilles heel for a surgeon is overconfidence.

Charles Goldfarb: 10:19

That's well said, and I it is a it is a little bit of a balance, as one is starting a new practice to engage his or her partners show the appropriate amount of independence without the perceptions of overconfidence. It can be very tricky, and you have to sort of read the room, because you're sort of trying to thread the needle. And then there's the inevitable. Why is new surgeon Joe taking so long to do his carpal tunnels? And you know there most people for carpal tunnel will be just fine, but in bigger cases and complicated distro radius is one example, it may take you a little longer as a new fellow graduate, compared to a partner who's been around for 10 years. But people shouldn't give you grief for that. You take as long as you need to take you over schedule, which is point number two,

Chris Dy: 11:08

that's my that was my next one, perfect. But

Charles Goldfarb: 11:11

take, yeah, but take the time that's required to do a great job for the patient, but to the to the point of advice, over schedule, not ridiculously, but over schedule, because it takes some stress off yourself, and the perception that you're slow will be diminished by the fact that you're just scheduling accurately. Yeah,

Chris Dy: 11:33

I think that's completely valid advice and advice that you gave me starting out and and I used, and I'm now kind of at that point of figuring out the balance between over scheduling versus under scheduling in order to get just enough cases on but then also make sure that the next patients are arriving on time without creating a Yeah, it is a very fine line. So chuck all the dashboards. My scheduling accuracy is some of it's really under, really over scheduled. And, you know, I'm happy because it actually ends up finding a balance. But, you know, so that I think that's great advice. Other advice, I'd say, is that, at the beginning, be very micromanaging with regards to how the or is, you know, set up in terms of, you know, implants that you might need and the availability of reps, if you would like to have reps there, because those are things that either you can directly control and make sure that they're done correctly, or you have to make sure that the person who's doing it knows your preferences and just touch base with them regularly. Because even, as we've learned, you know, even far out into practice, some of that stuff can slip through the cracks and really affect

Charles Goldfarb: 12:42

a day. Yeah, and it's easier once you're experienced to sort of pivot and switch it up and figure things out. You don't want to be doing a lot of that early in practice because of an oversight by you or by anyone where the correct equipment wasn't there. So I agree, be very careful about that. Talk through it a lot. You know, find the person you trust in your new or to make sure you have what you need. I think that's great advice. Number four, I would say, is, you know, outside of the or developing a team is incredibly important, because you are one part of a team, and your nurse, your ma, your athletic trainer, whoever it may be is, I would say, equally as critical to what you put forth in your community, how people see you and your practice, and hopefully you had a hand in hiring the person. And you certainly need to work together to figure it out, but getting the right person is incredibly important.

Chris Dy: 13:46

Yeah, I think that's key. I mean, I've just gone through a transition recently, and have been fortunate that the person that we've hired is fantastic, and I'm on my best behavior to hope that that she stays for quite a while. I was fortunate enough to have my first Ma was with me since I started, and was with me for almost nine, oh, maybe around nine years. So that was a great run. And she kind of our relationship and our working, you know, our ability to work together just kind of grew so she probably took on more than she should have been, just because she kind of was there, kind of watching it ramp up. So it's a lot to walk into, but I think taking care of that relationship being a leader, but also leading from the front, in terms of being willing to do everything that needs to be done, to get a clinic together, and making it like a team and less of a hierarchy is really important. Yep, I guess at point number five would be to develop a relationship in the community with the therapy groups, you know, establish yourself in ways that as much as possible. And we talked before in our marketing podcast with with Amanda about, you know, going and visiting physician practices. But. Think finding ways to make inroads with the various therapy groups in your communities is very helpful, and I've found that to be an incredibly helpful resource in terms of doing kind of lunch and learn, or kind of after after clinic sessions where you just go and talk about a topic and get to know them.

Charles Goldfarb: 15:15

Yeah, a good use of your time. And along those same lines, if you have partners that might benefit from your help, whether your sports partner is doing certain cases those relationships are you just have to develop them. They have to grow to trust you. My number six is, most of us start with a practice that's a little slow, that can be frustrating. So you can use your time, as Chris just said, but try to find a way to enjoy that time, and don't just lament that you're not busier, because you will presumably get busy quickly enough, and then you'll miss that time. So do things in that time which you will not have the opportunity to do later, whether that's spending more time with your family. You don't want to be seen as not in the office and not being around, but spending time with the family, developing your practice reading, the reading and the preparation shouldn't stop. In fact, I don't think I ever read as much as I did during my first year, I over prepared for every case, and that's critical.

Chris Dy: 16:13

I think, in the first five years, I read for every case, whether it was carpal tunnel, trigger finger, I just looked at the notes that I had. And then this kind of goes back to the people that are in training now. I mean, develop your note taking system. I was just talking with one of our PGY threes. Trey is fantastic. And we were talking about the hardest transition between being a two and a three. And I talked about this with Dr Aline to our residency director. Two, you're just trying to figure out where your hands are. Three, you're actually tasked with being a primary surgeon in so many ways, and that jump is big, and the preparation needed to get there is big. And I remember struggling, and everybody does as a mid level resident, trying to figure out what your note taking system and you know, for those that are graduating, you've probably figured out your note taking system, but continue to fall back on those notes, because those the same notes you're going to use for board preparation when you're going to take your boards. So, you know, I think that that's a critical thing, is read for every case, even if it's just looking through your old notes. So you're always prepared. Yesterday, in the plexus, I was talking with David, and we were saying, how, you know it sometimes a carpal tunnel is more stressful than a plexus in the way that if something doesn't go perfect in a plexus, there's so many things you could say, well, you know, bad injury. There are only a certain number of people in the country or the world that do this, and you know, they understand how challenging this is. But a carpal tunnel, there's no room for error in a carpal tunnel. You've got to be perfect every time. So that's the bar. So you got to prepare as such.

Charles Goldfarb: 17:46

Yeah, I really like that. And I also like your point. You know, every level, from intern, maybe, from medical student to intern to residency stages to fellowship to faculty, you're seeing things differently, and you're getting different things out of the case. And so that's part of the challenge. That's why it's so nice. When we do operate with our fellows in the middle of the night, even if we don't need to be there, for example, a flexor tendonitis, they acknowledge they get something out of it when we're there with them, and I think I still get something out of it. Maybe it's more enjoyment or or the moment, rather than something technical. But I think every step you kind of reconsider, when you're a two versus a three versus a chief, it's just a really, really fun development process.

Chris Dy: 18:33

That's the joy of surgery, right? You know, it's the being able to see the differences in each case and what you take out of it, for sure. Do you have any final points of wisdom? I will defer to you as the this, the more senior member of this team to close us out,

Charles Goldfarb: 18:52

yeah, I think the if we have a point number seven is you're never on an island, whether that's local help or, you know, we get both. Get joy out of the communications regarding case questions and case preparation from fellows at from you know, last year's fellows, 10 year ago, fellows, I still text regularly with two fellows that do a lot of sports that were 15 plus years out. And that's more of a we all chime in equally, rather than, you know, looking for advice from one of the one of our attendings. But I think you're never on an island, and the key to that is, you know, don't be shy. Maybe share the wealth. Don't, don't text or email the same person over and over and over. But don't be shy, because that's what your fellowship mentors are there for.

Chris Dy: 19:39

Yeah, I'm doing a meeting later today, with one of our fellowship graduates from a couple years ago, Lauren Wessel, who's been on the podcast, we're going to talk about a case, as well as talk about just kind of how, how interactions with residents and medical students for research, and how to, you know, work with that. So, yeah, you're never on an island. Your fellowship doesn't end after one year. Clearly. The relationship changes, but don't be a stranger. So hopefully, you know that's helpful to those that are graduating. Congratulations on finishing what is likely the last aspect of your training. And you know, make sure to acknowledge your mentors as you go through the process, or have a little graduation dinner for our graduating fellows, in which they have selected a faculty mentor to give a few words. The question came up during the plexus yesterday, whether this is a, you know, more of a roast, or more of a speech? And the answer was, yes, we'll see you've been entrusted with us speaking for one of our graduates. So we'll see what you come up with. Chuck,

Charles Goldfarb: 20:43

yeah, it's been low key in the past. I'm not gonna roast anybody. Others might. Yeah, I actually, I have an idea of how to roast Adam. So we'll see. Maybe, before we turn clinical, I'd like to thank checkpoint surgical that is continuing to expand their biomaterial portfolio portfolio with the launch of ACM shield, soft tissue barrier. ACM shield is a is a dehydrated placental membrane allograft for use as a protective barrier in surgical applications, comprised

Chris Dy: 21:15

of the complete intact layers of amniotic tissue and minimally processed to preserve the native structure of the tissue. ACM shield is an ideal protective barrier and extracellular matrix scaffold for use in a variety of surgical applications, such as nerve and tendon repair. To learn more, visit checkpointsurgical.com

Charles Goldfarb: 21:35

I might be visiting to learn more about this product. It's a little over my head.

Chris Dy: 21:39

It is. It's, you know, it's a little bit of a, you know, a new thing for checkpoints. So we'll see, we'll see how they do with it. It's funny every time that. So when we do our Plexus or days, we oftentimes will call for nerve stimulators. And both Dr Brogan and I have to disclose our conflicts of interest as we as we call for said stimulators, you know. And David, David occasionally listens to the podcast, I think, not by choice, because I think it comes up on his queue when, when he's running and for many hours and doesn't have the ability to readily change it. So occasionally he listens to us and provide some, I'll say, feedback to us about the the podcast during these long cases. So yeah,

Charles Goldfarb: 22:19

that's funny. Yeah, I haven't heard any feedback, but you guys spend more time together. That's funny. So I think we talked about two different clinical topics. Do you have a choice of which one we will pursue?

Chris Dy: 22:28

Well, it's summertime. So you know summertime typically means of hot and heavy call with high high energy trauma, at least in St Louis. And I'm realizing more and more that I think in St Louis we see some real stuff. Like, you see real stuff here, of all varieties. I mean, I remember moving here, graduating residency from Manhattan, and coming here and saying, I don't even know what these mechanisms of injury are like. I had to Google what an auger was, because I, you know, I It's not how I grew up, like, you know, it's nothing that I would have seen in Manhattan or Miami. So, you know, you see some real stuff. Here you see high velocity stuff. I was talking to one of our trauma surgeons, which OB yesterday. He's like, Yeah, you know, this is this place is it's the real deal in terms of mechanism of injury. So I remember a bad case when I was a fellow, a patient, we actually ended

Charles Goldfarb: 23:14

up wait before your case. So let's talk about some of those mechanisms. This is, this is good. This is good stuff. So we have the traditional city trauma, which is MVCs, obviously, in St Louis, we have gunshot wounds, we have stabbings, all that stuff. That's kind of the

Chris Dy: 23:31

America's a very nice place all of you that are listening,

Charles Goldfarb: 23:35

yes, yeah. And then we have sort of outdoor activities. So we have our share of bike injuries and scooter injuries and all 10 vehicles, four wheelers, side by sides, which is sort of an ATV, if you ask me, all

Chris Dy: 23:51

activities that my children will not be participating in. With my knowledge, based on everyone listening to me like that, dude is like such a wuss. Doesn't bike, he doesn't swim.

Charles Goldfarb: 24:02

You can only minimize risk to a certain degree. Yeah, I think it's the mixture of the city and the rural engagements, and we get it all. Which is, which is interesting.

Chris Dy: 24:13

Yeah. I mean, honestly, in our multicenter Plexus study, you know, the number of people that are hurt by falling trees in Missouri is pretty ridiculous. So we had a role. Like, I said, like, four or five people within the span of six months were hurt by falling trees. Now, part of that is because they were cutting the trees down for work or whatever. But, I mean, that's terrifying, like, you know, well, so we'll also see industrial type injuries, you know, I remember one Plexus was from a conveyor belt horseback riding, which is where this other case that I was about to mention comes in barges. We are

Charles Goldfarb: 24:49

on the barge. Oh, I've had a lot of barge injuries. Yeah,

Chris Dy: 24:53

yeah, railroad. There's one of our Plexus patients came off of a had a railroad accident, a real bad one. And then, yeah, the auger I mentioned, that's a farming instrument or a farming machine. I believe it's used for corn I'm gonna get.

Charles Goldfarb: 25:13

And then one of the ones, which I did grow up in Alabama, not terribly rural, but I didn't have exposure to wood splitters. Wood splitters are one of the worst mechanisms of injury, and for those of you hadn't seen it, it's worth a Google or YouTube. And essentially, you put the wood in this machine that sucks it in and splits it with a very sharp device, and hands and wood splitters do not go well together.

Chris Dy: 25:37

Yeah, and then I'm just a classic. Oh, it's nice spring or fall weather. I'm going to get to the wood shop. So there's a circular saw the table saw the standard kind of stuff with that. So yes, that's the mechanisms of injury that at least we see here in the good old son, Louis. So anyway, this patient, when I was a when I was a fellow, she had a very bad radio carpal fracture dislocation. So the fracture action was largely on the distal radius. So the carpus itself was not fractured, but the carpus was completely dislocated. Fell off on the radial side, so and then was completely dislocated dorsally as well. And so she was horseback riding, was having media, nerve paresthesias. So this was a case where, you know, what do you think about trying close reduction in the emergency room? Is there a role for that? And what's your sense of timing on this? Is this, if you get a good close reduction, you send her out, or is this something that you probably should go more urgently? Yeah,

Charles Goldfarb: 26:40

great, great points. I would say a couple things. First, typically, hey, I can say this, they're open injuries. And if it's that big of a trauma and that big of a radiocarbon or severe enough disc radius fracture dislocation, they're often open injuries. And so that does affect your timing a little bit. I will say we had this discussion yesterday. Not every open distur radius fracture needs to go to the operating room, you know, but the bigger ones with more trauma, a probably need to go to operating room and B, a closed reduction is almost always a good idea. You don't want to slow down things that the operating room happens to be open, and you can get there, but you'd like to get things at least better aligned, to take some soft tissue tension away, decrease the immediate swelling that might happen, take pressure off the median nerve. All of those are, in my mind, good reasons to likely do a closed

Chris Dy: 27:36

reduction. Yeah, and for pain, I mean, you know, honestly, like with your with your hands sitting sideways. You know that, you know, that hurts. So, you know, when I've seen this, it's been kind of, you know, a type one, sometimes for the ulna from that pressure on the ulnar side of the skin, with everything falling radially, and other times for the radius itself, sometimes accompanied by a styloid fracture. And we should probably differentiate, you know, and be careful, you know. So there are distal radius fractures with intra articular extension, in which you will have kind of a very violent injury that will displace the carpus and the distal fragment in a radial direction. Then there's like a true radiocarpal dislocation, which is slightly different beast. But if I guess, for this, I'm talking more about a bad distal radius fracture in which the carpus goes with the distal fragment.

Charles Goldfarb: 28:23

Yeah, I think that's a really important point. Radial carpal dislocations are rare. They definitely happen, but they're rare. More likely is a severe distal radius fracture where you sort of have the articular surface going with the carpus, which is 100% displaced and almost by definition, you have a TFCC tear. Now, that could be a soft tissue only TFCC tear, or that could be a ulna styloid that's large and, you know, but, but I think that is what we're talking about. Thanks for clarifying, and that's what we're sort of going to problem solve.

Chris Dy: 28:57

Yeah, so, I mean, so we've done a closed reduction. It's reasonable. Do you get a CT scan? I've had people ask this, and I don't feel strongly about it, because, honestly, it's not going to change a whole lot of what we do, but sometimes it can be helpful, if you're bold enough to go for fracture fixation right away.

Charles Goldfarb: 29:13

Yeah, I'm never against it. I think for fellows entering practice is probably not a bad idea. If you're not 100% comfortable with the bony status, I usually don't get a CT scan this situation.

Chris Dy: 29:28

So timing wise, if the patient's paresthesias are stable or potentially resolving with the after the close reduction and they're feeling better, What's your general and there's no other poly trauma kind of issues. This is an isolated injury. So what are you thinking in terms of timing?

Charles Goldfarb: 29:44

If it's a closed injury, and if you get reasonable alignment, I think you can do it semi electively, if it's an open injury and you don't have a great reduction, I guess I would say in the first 24 hours, ideally, something like that, maybe even a little faster, depending on the size. Of the open injury. How do you think about it? I agree.

Chris Dy: 30:02

I mean, I think if the median nerve paresthesia have not gotten better, that changes my my threshold in terms of timing, I would probably move it more urgently. You know, I think that if you don't have a great reduction, that soft tissue swelling is not going to get any better, and you might as well just, just

Charles Goldfarb: 30:19

go one of you know, doing a carpal tunnel release is typically advisable in these situations, even though it might be a bruised median nerve and not truly a hematoma in the carpal tunnel. But what you don't want to have happen is you do a great surgery, you crack, you have great bony alignment, and you the patient wakes up without a carpal tunnel release, and they still have tingling in your fingers, and then you're going to worry about it. And maybe, you know, if there truly was hematoma in the carpal tunnel, you've done the patient a disservice. So I sort of make it a habit to do a carpal tunnel release as part of the procedure. I'm sure you do as well.

Chris Dy: 30:59

I think so too. I mean, I think that just as hand surgeons were more likely to offer that procedure, you know, so I know that a lot of in a lot of places, general orthopods and trauma surgeons will be doing this, and they're probably just because they're lower comfort level with doing a carpal tunnel release, they are less likely to do it. And I think that's been borne out in the literature. But I think you've you never really regret doing it. And I think this is different than kind of the standard, you know, carpal tunnel syndrome patient, you know, the points of compression, I think are different the it's the volar anti brachial fascia that is right underneath the skin of the wrist crease, vulnerably, that is super tight in these patients. So while I don't connect the incisions, if I have a vulner approach, I will do kind of a separate carpal tunnel incision. I do make sure that I can see that I fully released the vulnerabicial fascia, the proximal aspect of the transverse carpal ligament. However you want to think about it directly. And I look and I make sure I pass my tenotomies of another instrument underneath, from the palm incision into the wrist or a forearm incision to make sure, because I've been burned by that, and I think that's the compressive point. And then you can access whatever hematoma is there, although I agree hematoma is relatively rare,

Charles Goldfarb: 32:13

yeah. And these are ones where you need to be a little careful and avoid the temptation to ever slide, because the anatomy can be so skewed that you may you know it's just a little riskier, but all good points. So, so you've gotten a reasonable reduction. Let's say you get the operating room eight hours later, you do your carpal tunnel release, and you're looking at a very unstable, just a radius fracture. You're looking at a unstable Dr, J, what's your first thought? How do you how do you think about it? Well, I

Chris Dy: 32:47

mean, so I would always, for me, I'd call for my standard disadraus fracture set of choice. I'd also call for a mini frag set in case I needed to do a little bit of fragment specific stuff on the fly. That's just my choice. I mean, if your disadra set has all fragment specific stuff that you like. And then I would also make sure to call for your spanning plate of choice, because I think that this is one where I have a very low threshold for a spanning plate. Now listen, spanning plates are not a panacea. I think that there was a period of time in the kind of late 2010s where everybody was doing spanning plates because of the literature that was supporting their use. I think things have settled back. I mean, I don't love taking somebody back for that second surgery, but I do think there's a utility, particularly not in this case. You know, this isn't a polytrauma case, but if it's a polytrauma case, and you know they're probably going to be needing you need to do some element of weight bearing through that upper extremity. If they've got a lower extremity injury too. That is very helpful, and that's where it came out of, really an experience in Seattle that Doug Handel published, and I know the Duke Group published about it as well. But, I mean, that's the best use of it, but I think it's been used more and more for isolated risk trauma. And I don't love using it all the time, but I like having it available. Yeah,

Charles Goldfarb: 33:57

it was interesting. I wasn't sure if you'd bring up this this point, you can overuse a spanning plate. And I personally believe, I've seen that when patients are treated in another city, or come here for another opinion, they've been treated with a spanning plate. I have sometimes wondered why a spanning plate was utilized. I think in some ways it can be simpler, I think to get and hold a reduction, but I don't know that it's a better treatment, and I'm not sure it's always the right treatment. But in a severe fracture, especially with a very small distal radius articular fragment, I think it's an unbelievable, unbelievably helpful option.

Chris Dy: 34:39

Yeah, I mean my Honestly, my default in the absence, like a very complex radius that doesn't have a substantial, you know, carpal, carpal sub dislocation type component, I like to fix them. And, you know, just, you know, it's not usually, it's usually not just a volar plate. So to say they can be more challenging. But even sometimes with a spanning plate, there are components. Components that are better addressed, I think, with some additional fixation, whether that's through K wires or fragment specific fixation. Usually it's the vulnerate facet or that dorsal ulnar corner that can be really well dressed. And sometimes you know that that radial styloid type split can be very nicely addressed through a through a separate fixation. So I like to see how things are lying after the close reduction, and then decide, you know what to do. And if we're just, if things keep falling off, or things don't feel super solid, then I go to the spanning plate. But if I can get, you know, for example, by columnar, you know, ideally orthogonal fixation, I think that goes a long way.

Charles Goldfarb: 35:39

Yeah, and I don't mind going both dorsal and bowler for a dorsal plate, bowler plate, if I think I can get definitive fixation at that first setting. I do think that is less commonly done with the option of the spanning plate. In other words, you get your general stability and alignment with your spanning plate, and then maybe do some more technical moves, either with a volar plate, a volar hook plate, or fragment specific plate, or even k wires. I'm a big fan of getting your major reduction holding with a spanning plate and then using K wires. Yeah, absolutely.

Chris Dy: 36:15

I mean, you've already paid the penalty for the dorsal approach with, you know, the spanning plate. You're not doing a formal dorsal, you know, intra articular exploration normally when you're doing the spanning plate, but you've already got the swelling and saw in the soft tissues on the dorsal side at that point. But I like the thought about the K wires. So if you come, I'm sorry, I was gonna say, if you come to doing the spanning plate, technically, how do you how do you dress? That is, there one particular type of plate that you use, you know, I know that all the manufacturers now have a spanning plate,

Charles Goldfarb: 36:45

yeah, and you know, your choice of the spanning plates, to me, does it go to the second metacarpal or third metacarpal? Does it have a sort of flare mid plate that can allow you to put screws either in a distal radius or the carpus? Or is it just a straight, smallish plate, I will say the I do like a thin, straight plate that you can put in with a couple of small incisions. The benefit is you can take it out with one or two small incisions, rather than having to open the entire dorsal approach. But in certain cases, it is nice to have that flare mid plate to light to put separate screws in. So I don't, I'm not. Wed to a particular manufacturer for this, because I think there's different benefits to different plates.

Chris Dy: 37:37

Yeah, absolutely. I mean, I tend to use, like a thin, straight, 2427, Combi plate. That just tends to be my go to but I see the benefit potentially I have, not from what I remember taking advantage of the kind of those mid plate opportunities to put some fixation in the distal fragment. I tend to use it truly like an internal, external fixator, yeah,

Charles Goldfarb: 37:59

and I think that's right, but I think depending on the fracture, sometimes that's helpful. And I'll say that occasionally Putting a screw in the carpus is helpful, if you're just grossly unstable. That has not, not commonly, but has been really helpful to me. So any, I don't think there's any necessary, necessarily, any pearls about how to fixate dorsally?

Chris Dy: 38:20

No, I think there are a couple. I mean, you know, I think, how do you decide between second and third? Metacarpal, distally,

Charles Goldfarb: 38:27

essentially, without sounding too Cavalier, I almost always go to the third, even though some of them are designed to go to the second. I like to have a little ulnar deviation resting position, which that can be helpful with, you know, putting it on the second but it's just sort of how it sits. To me, I don't know that there's a, I don't have a particular algorithm for that, do you? I don't, I know there

Chris Dy: 38:48

have been numerous biomechanical studies trying to look at this. I don't, honestly, I don't get matters that much. Not the sound glib, but like it really, I do think trying to get the restoration of radial length is probably the best consideration for me, and I find that's that's more reliable going to the third. And then I think the other technical Pearl is, I remember during fellowship, learning from, I think it was either you or Ryan kalfe that when you're I fixed distally first, and then when you're going to fix proximally, instead of having the hand pronated on the hand table. You know, take it off of the hand table, bend the elbow up and have it in neutral forearm position. Because if you, if you fix proximally with the palm flat, with the forearm pronated, it's going to push you radially, if you put, push the position of the plate radial on the radius. And if you supinate, or not supinate, but get them into neutral form, rotation off of the table. And for those of you watching on YouTube, I'm demonstrating that it gets you more centrally on the radius, which I think, if you're just kind of in the weeds and you're not thinking about it, you'll regret it. Yeah, and it's

Charles Goldfarb: 39:53

not like you have to do the whole case in that position, but you're right, I think. And in general, a dorsal approach with a pronated disc. Radius can present its own set of challenges. And so that is the benefit of fixating at the metacarpal level. First get a screw in in a neutral rotation posture, and then finish your fixation. And that can be really helpful. And I think there is a fine line you do want to get your length back, ideally, you're not truly distracting the carpus like you might do a little bit with an external fixer, and if you are distracting, it's just a little bit you can over distract these and that has been associated with complex regional pain syndrome. So you do have to be a little bit careful,

Chris Dy: 40:32

and you'll pay penalty with wrist motion down the line as well. But the CRPS is the pressing concern for me, so I totally agree with that. I don't know. I mean, if you look at the literature supporting the spanning plate, use the wrist motion is very good at, you know, six, 912, months. I do think they have some more limitations in terms of wrist motion than if you had not use the spanning plate. But also that's, I think it's part of the penalty of having such a bad trauma, too. So I can't say it's the spanning plate itself that's causing that.

Charles Goldfarb: 41:02

Yes, I totally agree with that. So my sequence of steps, and I don't, doesn't matter if you do crop total, first or last. I often just do it first to get it out of the way. And I often try to do the smaller surgery. No matter what the combo surgery is, I try to do the smaller surgery first to minimize the risk of forgetting. But forgetting? No,

Chris Dy: 41:21

it's true. I did a case a couple of weeks I was I looked at everybody room said, do not let us forget to do the carpal tunnel. And I immediately started to do the carpal tunnel first, just, I wouldn't forget. So

Charles Goldfarb: 41:31

carp tunnel first, spanning plate second. However, you need to get extra fixation. We need extra fixation. If you have a bowl or ulnar lunate facet, you want to put a little plate there. If you have a larger styloid fragment, you want to put some K wires. That's the next step, for sure. And then for me, just in, I'd love your thoughts. And then the last step is, as always, assess your Dr J critically, assess your forearm rotation. And if there's a large ulnar styloid fragment, fix it, and you can fix it with a K wire in these situations. I don't get super aggressive with open TFCC repair or anything like that, but fix your ulna style with a K wire and they can make a big difference.

Chris Dy: 42:14

Yeah, no, no, I totally agree. I think that assessing that drej At the end is critical. You know, as we wrote in one of our papers that is a critical step of fixing a disarray is fracture, and it's often a step that gets overlooked because I'm assessing that as I'm asking them to bring in the floor for the final films. So I when I'm working with a trainee I haven't worked with before, I tell them this is what I'm doing, as you know. Just don't forget to do this when you're out in practice. And then lastly, we talked about doing the carpal tunnel release. One advantage of doing the carpal tunnel release is that I have no qualms with them now having a block, which oftentimes is very helpful in terms of pain control now that may or may not be offered at your center, pre op or post op if definitely, if they've had a pre op block, for sure, I'm releasing the carpal tunnel because I have no option of assessing neurostatus afterwards. I still have some fond memories of a case during fellowship in which, you know, the faculty said, go ahead and do a block, and then we didn't do a carpal tunnel release, and I had to have a very awkward conversation of why I couldn't do a thorough neuro exam. It didn't go for a while. You can guess which faculty that was okay, but yeah, so I typically will say, if you're going to, if you're thinking about a block, which I think can be a good thing from a pain control perspective, for sure. Do the carpal tunnel release?

Charles Goldfarb: 43:27

Yeah, the only caveat with a block, and I agree completely about the carp tunnel, if it's a even more significant trauma than typically having a compartment syndrome in the back of your mind, that would be the other thing to maybe hesitate. But a block is such a wonderful thing that you'd love to be able to do the block.

Chris Dy: 43:44

Yeah, absolutely. And I think that's really good point about the compartments. So that was a, you know, hot summertime trauma topic. We have probably another one lined up for the next episode.

Charles Goldfarb: 43:53

Yeah, last question, yeah. How is your Do you have a standard length of time where the plate stays in before you schedule the surgery to remove the spanning plate.

Chris Dy: 44:03

So first off, for the fellows that are graduating and you have your conversation beforehand with the patient that we're probably going to use a spanning plate. Make sure you dictate in your operative note, or your progress note that this that the spanning plate will be using. There is a planned second procedure, you know, because you just for so many reasons, it's good to have that in the documentation. And then I typically would say two or three months. I know that in one of the older series, they went four months. I think that's a little bit long to be honest with you, but I'd say probably two or three months. How about

Charles Goldfarb: 44:36

you? Yeah, what I tell the patient is three months. And if there's clear bony healing and patients getting antsy two months or two and a half months is fine. The beauty of it, especially if you don't have K wires, is you have been a removable brace shortly after surgery, and so they're showering, and they realize that having a stiff wrist, especially if you can rotate the form fully, having a stiff wrist, is not that big a deal. So most patients. Is work on their fingers, they work on their elbow, they work on their forearm, and they're okay, and they're not killing you about getting the plate out, and then you get the plate out, and they have one thing to worry about, and that's wrist motion,

Chris Dy: 45:10

right? Exactly. Do you do a little gentle manip as you take the plate out? Absolutely. Yeah, not too not too aggressive, though,

Charles Goldfarb: 45:19

not too aggressive. All right, all right. That was fun. That was

Chris Dy: 45:22

fun. Well, good luck to all of our graduating fellows, and if there are any other topics you want to discuss as you transition into practice, email us. Handpodcast@gmail.com

Charles Goldfarb: 45:32

love it. Have a good day. You too. Hey, Chris, that was fun. Let's do it again real soon.

Chris Dy: 45:38

Sounds good. Well, be sure to email us with topic suggestions and feedback, you can reach us at handpodcast@gmail.com

Charles Goldfarb: 45:45

and remember, please subscribe wherever you get your podcast,

Chris Dy: 45:48

and be sure to leave a review that helps us get the word out. Special,

Charles Goldfarb: 45:53

thanks to Peter Martin for the amazing music,

Chris Dy: 45:56

and remember, keep the upper hand come back next time you